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August 14, 2024 Weekly Issue

PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports, and more. Past issues of the PSNet Weekly Update are available to browse. WebM&M presents current and past monthly issues of Cases & Commentaries and Perspectives on Safety.

This Week’s Featured Articles

Aikens RC, Chen JH, Baiocchi M, et al. Med Decis Making. 2024;44(5):481-496.
Large electronic health record- or population-based datasets form the basis for many diagnostic error studies. This article raises the issue of data-driven feedback loop failures which occur when disease incidence, presentation, and risk factors are misunderstood in research and, therefore, future medical practice. For example, men presenting with "classic" symptoms of heart attack are more frequently targeted for evaluation than women with "atypical" symptoms, thereby resulting in underdiagnoses of heart attack in women and underrepresentation in the evidence base.
Badr S, Nahle T, Rahman S, et al. J Gen Intern Med. 2024;Epub Jul 19.
Patients and families can look at various rating systems to compare hospitals, nursing homes, and other healthcare providers. This study compared ratings of four national hospital rating organizations: Hospital Compare, Healthgrades, The Leapfrog Group, and US News and World Report. The results showed discordance between hospital ratings on several important overall and condition-specific measures, potentially causing confusion for patients seeking care.
Nguyen PTL, Phan TAT, Vo VBN, et al. Int J Clin Pharm. 2024;46(5):1024-1033.
The fast-paced and complex environment of the emergency department (ED) can threaten patient safety. In this meta-analysis, the pooled prevalence of medication errors in the ED was 22%. The researchers estimated that 36% of patients experienced a medication error in the ED, with about 43% of these errors being potentially harmful but without leading to death.
Estrada Alamo CE, Diatta F, Monsell SE, et al. Anesth Analg. 2024;138(5):938-950.
As interest in artificial intelligence (AI) in healthcare is increasing, clinician attitudes towards its integration are important to understand. In this study, about half of surveyed physician anesthesiologists had a positive attitude towards using AI in clinical practice and a similar proportion were curious about its use. Concerns included lack of transparency in AI algorithms, potential decreased earnings, and malpractice claims.
Oster CA, Woods E, Mumma J, et al. Jt Comm J Qual Patient Saf. 2024;50(10):724-736.
Investigating safety events can help healthcare organizations improve systems and processes to prevent future incidents. This article describes the development of an electronic apparent cause analysis (eACA) tool, which combines features from high reliability, human factors engineering, and just culture, to investigate and learn from near-miss safety events or events resulting in minimal harm.
Aikens RC, Chen JH, Baiocchi M, et al. Med Decis Making. 2024;44(5):481-496.
Large electronic health record- or population-based datasets form the basis for many diagnostic error studies. This article raises the issue of data-driven feedback loop failures which occur when disease incidence, presentation, and risk factors are misunderstood in research and, therefore, future medical practice. For example, men presenting with "classic" symptoms of heart attack are more frequently targeted for evaluation than women with "atypical" symptoms, thereby resulting in underdiagnoses of heart attack in women and underrepresentation in the evidence base.
Didion L, Whitfield C, Bishop P, et al. J Patient Saf. 2024;20(5):375-380.
Health systems are increasingly aiming to become high reliability organizations. This safety net hospital established systems for high reliability through leadership, safety culture, and robust process improvement with targeted areas for improvement in patient outcomes, public reputation, and lower cost of care. Patient outcomes (e.g., reduction in hospital-acquired infections) improved, which subsequently improved Hospital Compare star ratings. Efforts to achieve lower costs of care continue with improved efficiency of care and educating all clinicians on their contributions to hospital finances.
Badr S, Nahle T, Rahman S, et al. J Gen Intern Med. 2024;Epub Jul 19.
Patients and families can look at various rating systems to compare hospitals, nursing homes, and other healthcare providers. This study compared ratings of four national hospital rating organizations: Hospital Compare, Healthgrades, The Leapfrog Group, and US News and World Report. The results showed discordance between hospital ratings on several important overall and condition-specific measures, potentially causing confusion for patients seeking care.
Porter-Stransky KA, Horneffer-Ginter KJ, Bauler LD, et al. BMC Med Educ. 2024;24(1):800.
Psychological safety is when team members feel comfortable speaking up without fear of negative consequences. This study evaluated a multi-year medical school-wide initiative to improve psychological safety through education, departmental champions, and leadership training. The researchers identified significant improvements in employees’ perceptions of psychological safety at the departmental level but not institution-wide.
Adkins TJ, Zhang H, Lee TG. Nat Commun. 2024;15(1):6422.
In order to improve patient safety, it is important to understand behaviors and decision making following an error. This article explores the concept of post-error slowing. Through four experiments, researchers determined post-error slowing is not simply due to increased caution, but due to impaired cognitive processing, and leads to even more mistakes.
Jennings AA, Doherty AS, Clyne B, et al. Age Ageing. 2024;53(6):afae116.
An unintentional prescribing cascade occurs when a medication side effect is misinterpreted as a new symptom resulting in the initiation of a new medication. Interviews were conducted with patients, caregivers, physicians, pharmacists, and other experts for their perspectives on prescribing cascades in older adults. Adverse drug events, and therefore prescribing cascades, were accepted as unavoidable for older adults taking multiple medications. Clinicians felt challenged when balancing risks and benefits of further prescribing. None of the stakeholder groups felt like they had adequate information for a safe medication reconciliation which presents a missed opportunity to identify and stop prescribing cascades.
No results.
Howell MD. BMJ Qual Saf. 2024;33(11):748-754.
Artificial intelligence (AI) is transforming the way researchers and clinicians seek to improve patient safety. This article provides a primer on AI terminology (e.g., generative AI, large language models), opportunities for it to improve patient safety, and challenges such as bias and hallucinations.
Malgrat-Caballero S, Kannukene A, Orrego C. J Healthc Qual Res. 2024;39(5):315-326.
Residents of long-term care facilities are particularly vulnerable to patient safety risks. This systematic review including 66 studies evaluated tools used to identify adverse events in intermediate and long-term care centers (ILCCs). The authors found that most tools are designed to identify specific adverse events or safety risks (such as medication errors, falls, or infections). Common adverse events impacting this population include adverse drug events, delirium, malnutrition, pressure ulcers, and infections.
Nguyen PTL, Phan TAT, Vo VBN, et al. Int J Clin Pharm. 2024;46(5):1024-1033.
The fast-paced and complex environment of the emergency department (ED) can threaten patient safety. In this meta-analysis, the pooled prevalence of medication errors in the ED was 22%. The researchers estimated that 36% of patients experienced a medication error in the ED, with about 43% of these errors being potentially harmful but without leading to death.
Flynn C, Watson C, Patton D, et al. J Pediatr Nurs. 2024;78:e82-e89.
Burnout is often referred to as a psychological syndrome, characterized by feelings of energy depletion, dissociation from one's work or cynicism regarding one's job, and a reduction in professional efficacy. This review highlights the association of pediatric nurses' burnout and perceptions of patient safety. The studies showed a negative association between burnout and/or its individual components and safety attitude scoring and job satisfaction. Only four studies were identified, highlighting the need for more research into the emotional well-being of pediatric nurses.
Institute for Healthcare Improvement.
Artificial intelligence (AI) is rapidly expanding across a wide range of clinical and administrative health care functions. This webinar examined general AI implementation recommendations and examine its potential impact on the safety of clinical decision support, consumer-facing automated support tools, and records support.
First L. NBC5. August 1, 2024.
Medication mistakes involving children are common. This news segment provides suggestions for parents to help improve the safety of medication use with children at home. Tactics emphasized include caution regarding use of household spoons to dose liquid medications.
Watts PI. Nurs Clin North Am. 2024;59(3):345-510.
Simulation is an established method to examine nursing process resilience and develop non-technical skills to improve safety. Articles in this special issue cover topics such as team communication improvement, debriefing practices, and simulation training experience design.
Agency for Healthcare Quality and Research. Fed Register. October 02, 2024;89:80247-80249.
Surveys are acknowledged tools that enhance healthcare organizational knowledge of their safety culture. This notice calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Medical Office Survey on Patient Safety Culture Database information collection process. The deadline for submitting comments on this notification has passed.

This Month’s WebM&Ms

WebM&M Cases
Commentary by Brittany Newton, PharmD and Roslyn Seitz, MPH, MSN |
An adolescent with type 1 diabetes presented to the emergency department (ED) with dizziness, fatigue, and a “high” reading on her home blood glucose monitor. She was diagnosed with diabetic ketoacidosis (DKA) likely due to insulin pump malfunction. Despite initial treatment, her condition did not improve as expected. Later, it was discovered that an incorrect weight was used to calculate her insulin drip rate, based on a guessed weight provided by the patient upon admission. Once her actual weight was used to adjust treatment, her DKA resolved rapidly within 12 hours. The commentary discusses how human factors engineering and electronic health record (EHR) functionalities can optimize weight measurement during patient encounters and the role of clinical pharmacists in the ED to improve medication safety.
WebM&M Cases
Commentary by Robert M. Szabo, MD, MPH, FAOA |
A woman underwent surgery for carpal tunnel syndrome without complications and was discharged with instructions to avoid soaking her hand in water (to reduce infection risk) and return for suture removal in 10 days. Despite reporting symptoms such as warmth, redness, and pain in her wrist shortly after surgery, her concerns were not adequately addressed by the surgeon's office. The patient returned for suture removal and visit notes stated that the wound was not infected or swollen. However, the patient continued to report pain, swelling, redness and oozing at the incision site after suture removal. Two weeks later, she presented to the emergency department (ED) and diagnosed with a severe infection, leading to multiple hospitalizations and permanent impairment of her right hand. The commentary discusses the importance of preoperative discussions about post-operative care, including sterile practices, and the use of protocol-based management strategies for medical office personnel to ensure that patient interactions and communication are appropriately documented and acted upon
WebM&M Cases
Spotlight Case
Scott Zakaluzny, MD, FACS |
A 67-year-old man with severe low back pain was admitted to the hospital for anterior lumbar interbody fusion (ALIF) with bone autograft from the iliac crest. The surgical team had difficulty controlling bleeding and the patient left the operating room (OR) with the bone graft donor site open and oozing blood. In the postanesthesia care unit (PACU), the nurse called the attending physician three times to report hypotension and ongoing bleeding. Each time, the surgeon ordered hetastarch for volume expansion. Over the next 14 hours, the patient’s blood pressure remained at or below 90/60 with continued complaints of back and pelvic pain. The next morning, the patient was unresponsive and in severe hypovolemic shock. Electrocardiography confirmed a non-ST segment elevation myocardial infarction (NSTEMI). The patient was transferred to an intensive care unit and resuscitative efforts were initiated, but the patient expired from multiorgan failure resulting from hypovolemic shock. The commentary discusses appropriate management of ongoing intraoperative and postoperative bleeding and how a culture of safety can enable care team members to voice concerns about patient safety. 

This Month’s Perspectives

Dr. Chalapathy Venkatesan and Kathy Helak headshot image
Perspectives on Safety
Chalapathy Venkatesan, MD, MS, CPPS, Kathy Helak, MSN, BSN, RN, FACHE, CPPS, Zoe Sousane, BS, Cindy Manaoat Van, MHSA, CPPS |
Dr. Chalapathy Venkatesan is the Chief Quality and Safety Officer, and Kathy Helak is the Assistant Vice President for Patient Safety at Inova Health System. We spoke to them about Safety-II principles and their application at Inova.
Perspective
Chalapathy Venkatesan, MD, MS, CPPS, Kathy Helak, MSN, BSN, RN, FACHE, CPPS, Zoe Sousane, BS, Cindy Manaoat Van, MHSA, CPPS |
This piece provides an overview of Safety-II principles and discusses ways healthcare systems are integrating Safety-II principles into safety programs and care delivery.
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